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YR5 Obstetrics and Gynaecology > Miscarriage > Flashcards

Miscarriage Flashcards

1
Q

Define miscarriage.

A

spontaneous loss of a pregnancy before 24w of gestation.
Early: before 13w of gestation.
Late: 13 - 24w of gestation.

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2
Q

What is a threatened miscarriage?

A

Painless PV bleeding in the presence of a viable pregnancy in first 24w
Bleeding often less than menstruation
Os closed

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3
Q

What is a recurrent miscarriage?

A

spontaneous consecutive loss of 3 pregnancies before 24w of gestation.

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4
Q

What is complete miscarriage?

A

all POC have been expelled from the uterus + bleeding has stopped.

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5
Q

What is incomplete miscarriage?

A

non-viable pregnancy in which bleeding has begun but POC remains in the uterus.
Pain + PV bleeding
Os open

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6
Q

What is inevitable miscarriage?

A

non-viable pregnancy in which bleeding has begun + os is open, but POC remains in the uterus.

Heavy bleeding with clots + pain

Leads to incomplete or complete miscarriage.

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7
Q

What is missed miscarriage?

A

Non viable pregnancy identified on USS
No pain or bleeding

AKA delayed or silent miscarriage

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8
Q

What advice should be given if the woman is <6 weeks pregnant and is bleeding but not in pain?

A

Expectant Mx
Repeat pregnancy test after 7–10d

Return if test is +ve or if her Sx continue or worsen

-ve test means the pregnancy has miscarried.

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9
Q

What is the diagnostic tool of choice to assess the location and viability of the pregnancy?

A

TVUSS

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10
Q

What is the aetiology of miscarriage? What are risk factors for miscarriage?

A

Majority occur in 1st trimester

Most common cause: chromosome abnormality.
No cause of recurrence can be determined in ~50% of couples

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11
Q

What are signs and symptoms of miscarriage?

A

Pain

PV bleeding

Clotting

Open cervical os

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12
Q

What investigations should be carried out to confirm miscarriage?

A

Transvaginal USS: Empty fetal sac measuring >45mm OR fetal pole measuring >7mm without fetal heartbeat

Blood hCG - hCG should double every day - if it is not it is a miscarriage, if it is rising every day but not double it is ectopic

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13
Q

What symptoms of ectopic should be screened for in women with PV bleeding that are/ could be <15w pregnant?

A

Abdo or pelvic pain.
Gastro Sx: N+V
Dizziness, fainting or syncope.
Shoulder tip pain.
Urinary Sx
Passage of tissue.
Rectal pressure or pain on defecation

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14
Q

What signs of ectopic should be screened for in women with PV bleeding?

A

Abdominal tenderness
Pelvic tenderness
Adnexal tenderness.

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15
Q

Give 2 pregnancy-related conditions that can cause bleeding in the 1st +2nd trimesters

A

Ectopic

Molar pregnancy

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16
Q

Give 3 features that may indicate a molar pregnancy

A

Bleeding heavy + prolonged
Sx of pregnancy exaggerated
Uterus large for dates

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17
Q

Give 3 pregnancy-related conditions that can cause abdominal pain in the 1st + 2nd trimesters

A

Ruptured ovarian corpus luteal cyst.
Adnexal torsion.
Pregnancy-related degeneration of a fibroid “red degeneration”

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18
Q

List 6 non-pregnancy-related conditions that can cause bleeding in early pregnancy

A

Cervicitis, cervical ectropion, or cervical polyps.
Haemorrhoids
TRAUMA of cervix, vagina, or vulva.
Urethral bleeding.
Vaginitis.
CANCER of cervix, vagina, or vulva.

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19
Q

Give 6 non-pregnancy-related conditions that can cause abdominal pain in early pregnancy

A

MSK pain
Gastro: IBS, constipation
UTI/ Renal colic
PID
Ovarian cyst
Torsion of a fibroid

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20
Q

Which symptoms in combination with a positive pregnancy test require immediate admission to early pregnancy unit?

A

Abdominal pain + tenderness, or

Pelvic tenderness, or

Cervical motion tenderness.

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21
Q

If there is no abdominal pain and tenderness, pelvic/ cervical motion tenderness and the woman is >,6w pregnant or of uncertain gestation how should they be managed?

A

Refer to early pregnancy assessment unit
(urgency of referral depends on clinical presentation)

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22
Q

When should you arrange immediate ambulance transfer to hospital for a woman presenting with bleeding or any other Sx suggestive of an early pregnancy complication ?

A

If haemodynamic instability: pallor, tachycardia, hypotension, shock, + collapse.

If significant concern about the degree of bleeding or pain.

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23
Q

What happens if viability of an IU pregnancy can’t be established because the fetus is of insufficient size for a heartbeat to be visualized?

A

Repeat after min. 7d

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24
Q

How should women with threatened miscarriage be managed?

A

If bleeding worsens, or persists beyond 14d, she should have a further clinical assessment.

If bleeding stops, she should start or continue routine antenatal care.

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25
Q

What is conservative management for miscarriage?

A

If bleeding + pain settle (suggesting complete miscarriage), take a pregnancy test after 3w

Return to the hospital if it is positive.

Offer medical/ surgical Mx if >14d persistent Sx

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26
Q

In which 4 scenarios is conservative management inappropriate?

A

Increased risk of haemorrhage (e.g. pregnancy is in late 1st trimester)

Previous adverse +/or traumatic experience a/w pregnancy: stillbirth, miscarriage, or APH

Increased risk from effects of haemorrhage: coagulopathy or is unable to have a blood transfusion

Evidence of infection.

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27
Q

What is the medical management for miscarriage?

A

Misoprostol: oral or PV

Pregnancy test after 3w + return if positive.

28
Q

What is the mechanism of action of misoprostol in the management of miscarriage?

A

Prostaglandin analogue, binds to myometrial cells
Causes strong myometrial contractions leading to the expulsion of tissue

29
Q

When may surgical management of miscarriage be more appropriate?

A

If RPOC despite medical Tx
or
if ongoing Sx after 14 days of expectant Mx

30
Q

What are the options for surgical management of miscarriage?

A

Vacuum aspiration: LA as OP. “Suction curettage”

Surgical Mx in Theatre: GA “evacuation of RPOC”

31
Q

When should anti D be given? (10)

A

Invasive prenatal dx: amniocentesis, CVS

APH

ECV of fetus (inc. attempted).

Ectopic (regardless of Mx)

Evacuation of molar pregnancy.

Intrauterine death + stillbirth.

Intrauterine procedures (eg, insertion of shunts, embryo reduction).

Miscarriage or threatened miscarriage >12w gestation.

Therapeutic TOP (regardless of gestation, inc. Miscarriage <12w with med/ surgical Mx)

Delivery: normal, instrumental or caesarean section.

32
Q

What are complications of a miscarriage?

A

Incomplete evacuation of the uterus can result in placenta accreta in subsequent pregnancies

Post-evacuation uterine bleeding

Recurrent miscarriage

Asherman’s syndrome

Psychological dysfunction

33
Q

When can women try again for a baby?

A

After the first negative pregnancy test, wait one cycle.

34
Q

What are risk factors for miscarriage?

A

Maternal age
Previous miscarriage
Paternal age

35
Q

What is an ectopic pregnancy?

A

fertilised ovum implanting + maturing outside the uterine cavity.

36
Q

Where do most ectopics implant?

A

Ampulla of fallopian tube

37
Q

Where are ectopic pregnancies more dangerous?

A

Isthmus

38
Q

Give 7 RFs for ectopic pregnancy

A

Tubal damage: PID, surgery
Previous ectopic
Endometriosis
IUCD
POP
Maternal age >35y
Smoking
No identifiable cause in 1/3

39
Q

Give 3 complications of ectopic pregnancy

A

Tubal rupture (potentially fatal if Tx is delayed).

Recurrent ectopic pregnancy.

Grief, anxiety, or depression.

40
Q

Give 6 symptoms of ectopic pregnancy

A

6-8w amenorrhoea

Lower abdo pain (constant +/- unilateral)

PV bleeding (less than normal period)

Shoulder tip pain/ pain on defecation/ urination (peritoneal bleeding)

Dizziness, fainting, syncope

Sx of pregnancy- breast tenderness

41
Q

Give 2 signs of ectopic pregnancy

A

Pelvic + abdominal tenderness.
Cervical excitation

42
Q

What should be avoided when examining a patient with suspected ectopic?

A

DONT palpate for an adnexal or pelvic mass as this may increase the risk of rupture of an ectopic pregnancy if present.

43
Q

Where are women with a suspected ectopic pregnancy managed?

A

Stable: Investigated + managed in EPAU
Unstable: refer to ED

44
Q

What is the investigation of choice for an ectopic pregnancy?

A

TVUSS
(Pregnancy test: +ve)

45
Q

Which criteria must be fulfilled for an ectopic pregnancy to be managed expectantly?

A

<35mm
Unruptured
Asymptomatic
No fetal heartbeat
hCG <1000 IU/L

46
Q

Which criteria must be fulfilled for an ectopic pregnancy to be managed medically?

A

<35mm
Unruptured
No significant pain
No fetal heartbeat
hCG <1500 IU/L

47
Q

Which criteria must be fulfilled for an ectopic pregnancy to be managed surgically?

A

> 35mm
Can be ruptured
Pain
Visible fetal heartbeat
hCG >5000 IU/L

48
Q

Which forms of management are compatible with another intrauterine pregnancy?

A

Expectant
Surgical

49
Q

What does expectant management of ectopic involve?

A

close monitoring over 48h
If B-hCG levels rise again or Sx manifest intervention is performed.

50
Q

What is medical management of ectopic?

A

Methotrexate (parenteral)
Patient must attend f/u

51
Q

What is surgical management of ectopic?

A

Salpingectomy: 1st line if no other RF for infertility

Salpingotomy: consider if RFs for infertility e.g. contralateral tube damage

52
Q

What is salpingectomy and salpingotomy?

A

Salpingectomy: Fallopian tube removal

Salpingotomy: incision. Preservation of tube.

53
Q

What is termination of pregnancy?

A

Medical/ surgical way of ending a pregnancy

54
Q

What are the requirements for TOP to be legal?

A

Before 24w

2 registered medical practitioners must sign a legal document (in an emergency only 1 is needed)

Only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

55
Q

How quickly should TOP be performed?

A

Should not have to wait >2w from 1st referral to time of abortion.

56
Q

Give 5 contraindications to medical TOP

A

Known/ suspected ectopic pregnancy

Previous allergic reaction to mifepristone or misoprostol

Severe uncontrolled asthma

Chronic adrenal failure

Inherited porphyria

57
Q

What is medical TOP?

A

Mifepristone followed 48h later by misoprostal

58
Q

What is the MOA of Mifepristone and Misoprostal?

A

Mifepristone: anti-progesterone- cervical ripening + sensitisation to prostaglandin induced contractions

Misoprostal: Prostaglandin analogue- stimulates uterine contraction

59
Q

Where is medical TOP performed?

A

<12w: At home
>12w: medical facility preferred

60
Q

What is the most effective regimen for medical TOP?

A

Mifepristone 200mg orally, followed 24–48h later by
Misoprostol 800 micrograms taken by the vaginal, buccal or sublingual route.

61
Q

In medical TOP, if expulsion of the pregnancy has not occurred within 4h, what should be done?

A

A further 400 micrograms of misoprostol should be taken by the vaginal, buccal or sublingual route.

62
Q

What is surgical TOP?

A

<14w: vacuum aspiration

> 14w: dilation + evacuation

63
Q

What is vacuum aspiration for TOP?

A

Cervical preparation
If <14w can be done with LA if chosen (or sedation/ GA)

64
Q

What is dilation + evacuation for TOP?

A

Cervical preparation
GA
Forceps + vacuum aspiration
Safest + most effective method >14w

65
Q

What preparation is required before surgical TOP?

A

<12w: Mifepristone or Misoprostal
>12w: Mifepristone + Misoprostal + Osmotic dilators

66
Q

What dose of anti-D should be given if <20w gestation?

A

250 IU
No need to screen for FMH

67
Q

What dose of anti-D should be given if >20w gestation?

A

500 IU
Kleihauer test required

YR5 Obstetrics and Gynaecology (73 decks)

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